Chapter 4 Flashcards
abbreviation
A shortened form of a word
chart
“medical record”
communication
The exchange of information—a message sent is received and correctly interpreted by the intended person
conflict
A clash between opposing interests or ideas
diagnosis
The term used when symptoms, signs, or reasons for a problem are identified
Kardex
A type of card file that summarizes information found in the medical record—medications, treatments, diagnoses, routine care measures, equipment, and special needs
medical record
A written or electronic document of a person’s condition and response to treatment and care; often referred to as a chart or clinical record
prefix
A word element placed before a root; it changes the meaning of the word
progress note
A written description of the care given and the person’s response and progress
recording
The written account of care and observations; charting
reporting
The oral account of care and observations
root
A word element that contains the basic meaning of the word
suffix
A word element placed after a root; it changes the meaning of the word
word element
A part of a word
ADL
Activities of daily living
